Artificial Tanning 1 Artificial Tanning by Suburban Teenagers: A Survey on the Prevalence of and Motivations for Indoor Tanning in the Midwest Robert Levine (847)/940-1872 email@example.com Adlai E. Stevenson High School Lincolnshire, IL Artificial Tanning 1 Abstract Exposure to ultraviolet radiation (UVR), especially from artificial sources, has been shown to increase the risk for skin cancers. Although the incidence of skin cancers continues to climb in the United States, so too does the popularity of indoor tanning. A stratified random sample of students from a large, Midwestern high school, known for its academic excellence, was surveyed to quantify indoor tanning behaviors and sunscreen use. Attitudes toward tanning and the knowledge of the health risk associated with it were also examined. The percentage of respondents who tan indoors was 24%, increasing significantly with age. More girls (37%) tanned than boys (8%), and teenagers began to tan at a younger age. Most tanners (89%) indicated that they did so for appearance related reasons. Tanners were more likely to have a family member who tanned than non-tanners, and 11% of respondents reported having a parent who tanned. Although only 37% of respondents reported seeing an advertisement that expressed the dangers of tanning, a majority of students (92%) believed that indoor tanning was unhealthy. Finally, half of respondents reported using sunscreen regularly, with girls doing so more than boys. More teenagers than ever before are tanning indoors, disregarding substantial evidence that links this behavior to skin cancer. The results of this study detail this problematic trend and suggest a manner in which an educational campaign with committed resources can produce effective intervention. Artificial Tanning 1 Introduction The prevalence of skin cancer in our society demands an understanding of its causes if we are to control its proliferation. Over 1 million cases of nonmelanoma skin cancer are diagnosed yearly, and it is estimated that 55,100 new cases of melanoma will be diagnosed in 2004 alone (“Skin Cancer”, 2003, ¶ 1). Research has repeatedly shown that increased exposure to ultraviolet radiation (UVR), especially from artificial sources, can increase the risk for skin cancers. In the United States, the Skin Cancer Foundation (SCF) estimates that 28 million people tan indoors annually (“Case Against”, 2003, ¶ 1). Prompting this research is the alarming rise in the popularity of artificial tanning, a trend likened by some to cigarettes, with consequences of unforeseen magnitude in the teenage population (Gutfeld & Sangiorgio, 1993, ¶ 1). The high proportion of teenagers who tan indoors suggests that today’s youth are exposing themselves to increased levels of UVR (Geller et al., 2002). The short-term effect, having tanned skin, is mainly aesthetic. The problem is that serious long-term ramifications are often overlooked. The most common effects of exposure to UVR are premature skin aging, wrinkles, loss of skin elasticity, the development of dark patches (i.e. age spots or liver spots) and actinic keratoses, which are small rough or scaly spots generally considered to be precursors to cancer (“Actinic Keratosis”, 2003; “Sunlight and Ultraviolet Exposure”, 2003). These complications are minor compared to the heightened risk for developing skin cancers, namely basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma. Recent studies provide evidence for the connection between artificial tanning and skin cancers. Karagas et al. (2002) found that compared to non-tanners, Artificial Tanning 2 the use of tanning devices increased the likelihood of developing BCC by 1.5 times and SCC by 2.5 times. It further concluded that for every ten years earlier that a subject began use of a tanning device, the odds for BCC and SCC increased an additional 10% and 20%, respectively (Karagas et al.). A recent study by Veierød et al. (2003) tracked rates of melanoma for an eight year period in 106,379 women and found that a significantly increased risk of contracting melanoma was associated with indoor tanning use. Another study found similar results and noted that individuals who began artificial tanning before the age of 36 had 8.1 times greater risk for developing melanoma when compared to non-users (Westerdahl, Ingvar, Måsbäck, Jonsson, & Olsson, 2000). Although evidence clearly links artificial tanning to an increased risk of skin cancer, the majority of tanners seem willing to overlook it. A study of undergraduate students at a large Midwestern university found that 47% of surveyed students had used a tanning facility in the last year, while more than 90% of these students were aware of possible complications (Knight, Kirincich, Farmer, & Hood, 2002). If today’s youth realize that indoor tanning is dangerous, yet continue to patronize such facilities, it is vital that we come to understand why. To that end, this research seeks to quantify indoor tanning behaviors and pinpoint a student’s motivation for tanning indoors. Population data regarding sunscreen and tanning bed use was collected at a large, suburban high school by surveying a stratified random sample of students. In addition, the survey sought to determine whether students understand the inherent dangers of tanning indoors and the extent to which students have seen educational material about tanning. The student body of Artificial Tanning 3 4,362 was selected to be surveyed because indoor tanning appears widespread, and there is no known local campaign to educate students about its risks. This project can corroborate other population-based studies, as well as provide the groundwork for follow-up studies that can assess the effectiveness of implemented educational interventions or track skin cancer rates. Methods Participants The student body of a large, suburban high school was selected as the population to be surveyed. This Midwestern high school has maintained a high degree of academic excellence, having received the United States Department of Education "Excellence in Education" Blue Ribbon award in 1987, 1991, 1998, and 2002 (“2002- 2003 Profile”, 2003). According to the Washington Post’s Jay Mathews, this high school ranks 69th in the top public high schools in America (2003, table). The school is 84.2% White, 0.9% Black, 2.9% Hispanic, 12.0% Asian or Pacific Islander, and 0.1% Native American. (Illinois School Report Card, 2003, table “Students”). Please refer to Table 1 for further description of the student population. Design and Procedure The student body was stratified by class, and a simple random sample was taken from each grade level. This stratification was devised to better examine the hypothesized increase in tanning rates among older adolescents. The sampling procedure was designed to attain 100 responses from each grade in order to yield statistically salient results while still maintaining a manageable number of participants. Originally, 130 subjects were randomly selected in each grade, although an Artificial Tanning 4 unexpectedly high non-response bias was apparent shortly after the survey began. Subjects were randomly added one-by-one to each grade until 100 responses were attained. As evident in Table 1, this procedure explains why each grade has a different number of randomly selected students. Using the school’s published directory, in which a large percentage of students are listed, each student received a number within their class. A random number generator on the TI-89 was then used to select random numbers from each class. Each subject was telephoned between January 1st, 2004, and February 1st, 2004. Every willing subject responded to a survey, and responses were appropriately recorded. In an effort to minimize response bias, the telephone survey was scripted so that each subject heard the exact same instructions. The entire respondent survey can be found in Appendix A. Table 1. Class Size and Sampling Design Number Non- Sampling Randomly response Number of Stratum Enrollmenta Spaceb Selected bias (%) Responses Freshmen 1,143 1,071 150 33 100 Sophomore 1,158 1,110 174 43 100 Junior 1,040 999 142 30 100 Senior 1,021 972 163 39 100 Total 4,362 4,152 629 36 400 a Enrollment as of January 5, 2004. b Determined by the number of directory listings for that class. Artificial Tanning 5 Variables Demographics and skin color. Each respondent’s gender, age, and grade level was determined. Each was asked to classify his or her skin color on the following scale: very fair, fair or average, olive, or dark. This assessment was used to determine the approximate extent to which their skin would burn with exposure to UVR. In general, when exposed to UVR, very fair skin will burn and rarely tan; fair or average skin will tend to burn easily and tan minimally; an olive complexion rarely will burn and tans well; and dark skin color will almost never burn and will remain dark (“Darker Side”, 1996). Indoor tanning facility use. Each respondent was asked if he or she had ever been to a tanning salon. If the respondent answered yes, he or she was asked more detailed questions about their tanning behavior. The age when the respondent first tanned indoors was determined, as was the number of times he or she tanned in the last year on a scale of 1 to 5, 6 to 10, or greater than 10 times. Respondents were asked if they ever tanned for a school dance, how often they usually visited the tanning salon, and how long they tanned at each session. Finally, respondents answered true/false to descriptors that sought to identify their motivations for tanning: aesthetic appearance, cost, peer pressure, or in preparation for vacation. If the respondent had never been to a tanning salon, he or she responded to a series of true/false descriptors that sought to identify the reason: no desire, knowledge of the dangers, limited time, or cost. Artificial Tanning 6 Understanding the danger. To assess whether students understand the danger of indoor tanning, two questions were asked. Towards the beginning of the survey, students were asked: “Do you think artificial tanning is healthy?” Towards the end of the survey, students were asked: “Do you think artificial tanning is safe?” The subtle difference was intended to determine whether students truly understood the question, as well as assess the number of students who wavered on the question or changed their answer. Sunscreen use. Each respondent was asked whether he or she regularly used sunscreen. This quantified a major risk factor in the development of skin cancer. Familial tanning. Each respondent was asked whether anyone in their immediate family tanned indoors. This variable was included because previous studies have shown there may be a link between teenage tanning and parental tanning (Cokkinides, Weinstock, O'Connell, & Thun, 2002). Advertisements. Each respondent was asked whether he or she had ever seen advertisements for tanning salons. This was followed by a question that asked if students had ever seen educational signs or advertisements expressing the dangers of tanning. This variable, along with the student’s understanding of the dangers of tanning, helped quantify the effectiveness of educational campaigns. Artificial Tanning 7 Mobility. Each respondent was asked if he or she had a driver’s license and access to a car. It is hypothesized that students who want to patronize tanning salons will be more inclined to go if they are not dependent on their parents or older siblings to drive them. Risky behaviors. Each respondent was asked if he or she smoked cigarettes, a behavior that has been linked in a previous study to higher tanning rates (Welchsler, Rigotti, Gledhill-Hoyt, & Lee, 1998). Statistical Analysis. Data from each grade was compiled in a spreadsheet and then transferred to a statistical analysis program, Fathom Dynamics Statistics Software™. For each variable, the percentage of the sample population that responded in a particular way was determined, along with the 95% confidence interval (CI) that estimated the percentage of the entire population that exhibited that characteristic. The effects of different variables were considered by multivariate data analysis and significance was determined by two-proportion Z-tests with an alpha level of .05. Artificial Tanning 8 Results The survey included a total of 400 students, with 182 male and 218 female respondents. A frequency distribution of the population surveyed can be found in Table 2. Overall, 24% (95% CI = 0.20 to 0.28) of all respondents tanned indoors. As respondent age increased, so too did the percentage that tanned indoors. Table 3 shows this significant trend, along with the observation that girls tanned more than boys. Skin color apparently did not affect indoor tanning habits of respondents. Over half of all tanners (57%, [95% CI= 0.47 to 0.67]) reported that they tanned indoors 1-5 times in the last year, although 70% (95% CI= 0.58 to 0.83) of these tanners indicated no regular schedule for this activity. When students tanned indoors, the majority of these sessions lasted 15 minutes (34%, [95% CI= 0.24 to 0.43]) or 20 minutes (39%, [95% CI=0.29 to 0.49]), with no significant differences between grades. Surveyed tanners indicated they began tanning at a mean age of 14.72 years (95% CI= 14.46 to 14.97). The mean age at which freshmen respondents began tanning (13.33 years, [95% CI= 12.65 to 14.02]) was significantly lower than that of juniors (14.93 years, [95% CI= 14.51 to 15.36]) and seniors (15.38 years, [95% CI= 14.94 to 15.81]). When respondents were questioned about why they tanned indoors, most tanners (89%, [95% CI= 0.83 to 0.93]) indicated that they did so because they liked the way it made them look. Table 4 shows that significantly more Freshmen and Junior tanners specified that they also went tanning to achieve a base layer prior to vacation. Tanning prior to a school dance was measured and 66% (95% CI= 0.57 to 0.76) of all tanners reported such behavior. Interestingly enough, however, 81% (95% CI= 0.73 to Artificial Tanning 9 0.89) of tanners reported that having friends who tanned was not a motivation for tanning. Likewise, the cost of tanning did not appear to be relevant. When non-tanners were questioned about their reasons for not tanning, 91% (95% CI= 0.87 to 0.94) cited no desire to tan indoors. As Table 5 indicates, the majority (73%, [95% CI=0.68 to 0.78]) indicated that they refrained from tanning because they knew it was dangerous. Limited time and lack of money were not relevant factors. The impact of having a family member who tans was studied. The survey found that 25% (95% CI= 0.21 to 0.29) of all respondents had one or more family members who tanned indoors. Of the tanners, 47% (95% CI= 0.37 to 0.57) reported having a family member who tanned, while only 18% (95% CI= 0.14 to 0.22) of respondents who didn’t tan reported such. Furthermore, 11% (95% CI= 0.08 to 0.14) of respondents reported that a parent tanned indoors. A large majority of all surveyed students (92%, [95% CI= 0.89 to 0.95]) expressed the belief that artificial tanning is unhealthy. As Table 6 shows, no significant variation was seen between tanners versus non-tanners, though girls were more likely to think tanning was unhealthy (z=2.75, p<.006). Of interest, a variation on this question showed that 13% (95% CI= 0.10 to 0.17) of respondents believed indoor tanning to be safe, a significantly higher proportion than thought it to be healthy (8.0%, [95% CI=0.05 to 0.11], z=2.41, p<0.016). Furthermore, exposure to educational advertisements about the dangers of tanning had no effect on a student’s opinion on this matter. While 37% (95% CI=0.33 to 0.42) of all respondents indicated they had seen advertisements expressing the dangers of tanning, more than twice that amount, 81% (95% CI=0.77 to 0.84), reported having seen advertisements for tanning salons. Artificial Tanning 10 Half of all students surveyed (95% CI = 0.45 to 0.55) indicated that they regularly used sunscreen. These results are shown in Table 7. Overall, more girls reported regular sunscreen use than boys (z=2.50, p<.012). Respondents with very fair or average skin color used sunscreen more often than respondents with olive or dark skin. While most everyone of driving age indicated they had a license and access to a car, this variable proved to have little effect on tanning behaviors. Finally, the number of respondents who reported that they smoked was so small that it was deemed unusable and not considered as a factor in tanning behavior. Table 2. Sample Frequency Distribution Gender Age Skin Type Grade Very Fair or M F Mean Fair Average Olive Dark Freshmen 45 55 14.32 9 74 15 2 Sophomore 52 48 15.36 6 71 19 4 Junior 39 61 16.31 9 70 15 6 Senior 46 54 17.36 11 72 14 3 All Respondents 182 218 15.84 35 287 63 15 Note. Each grade has n=100. All Respondents is N=400. Artificial Tanning 11 Table 3. Prevalence of Indoor Tanning Salon Use Grade Proportion who Tan P-values Freshmen Total (n=100) 0.12 (0.06 to 0.18) Male (n=45) 0.02 (0.00 to 0.12) Female (n=55) ] .0065 0.20 (0.09 to 0.31) Sophomore Total (n=100) 0.21 (0.13 to 0.29) Male (n=52) 0.04 (0.00 to 0.13) ] .0000 Female (n=48) 0.40 (0.26 to 0.53) Junior Total (n=100) 0.30 (0.21 to 0.39) Male (n=39) 0.10 (0.03 to 0.24) ] .0005 Female (n=61) 0.43 (0.30 to 0.55) Senior Total (n=100) 0.32 (0.23 to 0.41) Male (n=46) 0.17 (0.08 to 0.31) Female (n=54) ] .0039 0.44 (0.31 to 0.58) All Respondents Total (N=400) 0.24 (0.20 to 0.28) Male (n=182) 0.08 (0.04 to 0.12) ] .0000 Female (n=218) 0.37 (0.30 to 0.43) Note. Sample proportions are given as the decimal followed by the 95% CI. To test the Ho (proportion “male” and proportion “female” are equal) a two-proportion Z-test was used. All P-values are two-sided. Artificial Tanning 12 Table 4. Motivational Analysis of Indoor Tanners Descriptor Grade Responded True Responded False P-values Freshmena 0.92 (0.62 to 1.00) 0.08 (0.00 to 0.38) .0000 I went tanning b Sophomore 0.86 (0.64 to 0.97) 0.14 (0.03 to 0.36) .0000 because I like c Junior 0.87 (0.69 to 0.96) 0.13 (0.04 to 0.31) .0000 how it makes me look. Seniord 0.94 (0.79 to 0.99) 0.06 (0.01 to 0.21) .0000 Totale 0.89 (0.83 to 0.93) 0.11 (0.04 to 0.17) .0000 I went tanning Freshmena 0.25 (0.05 to 0.57) 0.75 (0.43 to 0.95) .0143 because I got b Sophomore 0.29 (0.11 to 0.52) 0.71 (0.48 to 0.89) .0050 coupons or it c Junior 0.27 (0.12 to 0.46) 0.73 (0.54 to 0.88) .0003 was d inexpensive. Senior 0.22 (0.09 to 0.40) 0.78 (0.60 to 0.91) .0000 e Total 0.25 (0.17 to 0.34) 0.75 (0.66 to 0.83) .0000 Freshmena 0.25 (0.05 to 0.57) 0.75 (0.43 to 0.95) .0143 I went tanning b Sophomore 0.29 (0.11 to 0.52) 0.71 (0.48 to 0.89) .0050 because many c Junior 0.13 (0.04 to 0.30) 0.87 (0.70 to 0.96) .0000 of my friends d do it. Senior 0.16 (0.05 to 0.33) 0.84 (0.67 to 0.95) .0000 e Total 0.19 (0.11 to 0.27) 0.81 (0.73 to 0.89) .0000 Freshmena 0.83 (0.52 to 0.98) 0.17 (0.02 to 0.48) .0011 I went tanning b to get a base Sophomore 0.62 (0.38 to 0.82) 0.38 (0.18 to 0.62) .6190 c layer before Junior 0.67 (0.50 to 0.84) 0.33 (0.17 to 0.50) .0098 going on Senior d 0.59 (0.42 to 0.76) 0.41 (0.24 to 0.58) .1336 vacation. Totale 0.65 (0.56 to 0.75) 0.35 (0.25 to 0.44) .0000 Freshmena 0.42 (0.15 to 0.72) 0.58 (0.28 to 0.85) .4142 b I went tanning Sophomore 0.67 (0.43 to 0.85) 0.33 (0.15 to 0.57) .0308 c for a school Junior 0.77 (0.58 to 0.90) 0.23 (0.10 to 0.42) .0000 dance. Senior d 0.66 (0.49 to 0.82) 0.34 (0.18 to 0.51) .0124 e Total 0.66 (0.57 to 0.76) 0.34 (0.24 to 0.43) .0000 Note. Sample proportions are given as the decimal followed by the 95% CI. These are based on the total for each stratum and may not total to 1 due to rounding. To test the Ho (proportion “responded true” and proportion “responded false” are equal) a two-proportion Z-test was used. All P-values are two-sided. a b c d e n=12; n=21; n=30; n=32 ; n=95 Artificial Tanning 13 Table 5. Motivational Analysis of Non-Tanners Descriptor Grade Responded True Responded False Freshmena 0.86 (0.79 to 0.94) 0.14 (0.06 to 0.21) I have no Sophomoreb 0.95 (0.88 to 0.99) 0.05 (0.01 to 0.13) desire to go Juniorc 0.90 (0.81 to 0.96) 0.10 (0.04 to 0.20) artificial tanning. Seniord 0.91 (0.82 to 0.97) 0.09 (0.03 to 0.18) Totale 0.90 (0.87 to 0.94) 0.10 (0.06 to 0.13) Freshmena 0.69 (0.60 to 0.79) 0.31 (0.21 to 0.40) I don’t go Sophomoreb 0.72 (0.62 to 0.82) 0.28 (0.18 to 0.38) tanning Juniorc 0.81 (0.72 to 0.91) 0.19 (0.09 to 0.28) because I know it is dangerous. Seniord 0.69 (0.58 to 0.80) 0.31 (0.20 to 0.42) Totale 0.73 (0.68 to 0.78) 0.27 (0.22 to 0.32) Freshmena 0.33 (0.23 to 0.43) 0.67 (0.57 to 0.77) I don’t go Sophomoreb 0.33 (0.23 to 0.43) 0.67 (0.57 to 0.78) tanning because I don’t Juniorc 0.34 (0.23 to 0.45) 0.66 (0.55 to 0.77) have enough time. Seniord 0.19 (0.01 to 0.28) 0.81 (0.72 to 0.90) Totale 0.30 (0.25 to 0.35) 0.70 (0.65 to 0.75) Freshmena 0.13 (0.06 to 0.19) 0.88 (0.81 to 0.94) I don’t go Sophomoreb 0.13 (0.05 to 0.20) 0.87 (0.80 to 0.95) tanning because I don’t Juniorc 0.20 (0.11 to 0.29) 0.80 (0.71 to 0.89) have the money. Seniord 0.12 (0.05 to 0.22) 0.88 (0.78 to 0.95) Totale 0.14 (0.10 to 0.18) 0.86 (0.82 to 0.90) Note. Sample proportions are given as the decimal followed by the 95% CI. These are based on the total for each stratum and may not total to 1 due to rounding. Two-proportion Z-tests showed that all tests of Ho (proportion “responded true” and proportion “responded false” are equal) demonstrated significance at the .01 level. All P-values were two-sided. a b c d e n=88; n=79; n=70; n=68 ; n=305 Artificial Tanning 14 Table 6. Exposure to Advertisements and Attitudes Towards Indoor Tanning Descriptor Grade Sample Proportion P-values All Respondentsa 0.08 (0.05 to 0.11) Respondents Tannersb 0.09 (0.04 to 0.17) who think ].5443 Non-tannersc 0.08 (0.05 to 0.11) artificial tanning is healthy. Maled 0.12 (0.07 to 0.17) e ].0059 Female 0.05 (0.02 to 0.07) All Respondentsa 0.13 (0.10 to 0.17) Respondents Tannersb 0.21 (0.13 to 0.29) who think ].0102 Non-tannersc 0.11 (0.07 to 0.14) artificial tanning is safe. Maled 0.16 (0.11 to 0.21) ].1480 Femalee 0.11 (0.07 to 0.15) All Respondentsa 0.81 (0.77 to 0.84) Respondents Tannersb 0.77 (0.68 to 0.85) who have seen ].3028 advertisements Non-tannersc 0.82 (0.77 to 0.86) for tanning Maled 0.80 (0.74 to 0.86) salons. ].7020 Femalee 0.81 (0.76 to 0.86) Respondents All Respondentsa 0.37 (0.33 to 0.42) who have seen Tannersb 0.60 (0.50 to 0.70) advertisements c ].0000 Non-tanners 0.30 (0.25 to 0.35) expressing the dangers of Maled 0.23 (0.17 to 0.29) tanning. e ].0000 Female 0.49 (0.42 to 0.56) Note. Sample proportions are given as the decimal followed by the 95% CI. Two-proportion Z-tests were used to determine significance. All P-values are two-sided. a b c d e N=400; n=95; n=305; n=182 ; n=218 Artificial Tanning 15 Table 7: The Prevalence of Regular Sunscreen Use Grade Proportion who Use Sunscreen P-values Freshmen Total (n=100) 0.64 (0.55 to 0.73) Male (n=45) 0.49 (0.34 to 0.63) Female (n=55) 0.76 (0.65 to 0.88) ] .0044 Very Fair or Fair (n=83) 0.69 (0.59 to 0.79) Olive or Dark (n=17) 0.41 (0.18 to 0.67) ] .0314 Sophomore Total (n=100) 0.40 (0.30 to 0.50) Male (n=52) 0.37 (0.24 to 0.50) Female (n=48) 0.44 (0.30 to 0.58) ] .4621 Very Fair or Fair (n=77) 0.45 (0.34 to 0.57) Olive or Dark (n=23) 0.22 (0.07 to 0.44) ] .0416 Junior Total (n=100) 0.49 (0.39 to 0.59) Male (n=39) 0.46 (0.31 to 0.62) Female (n=61) 0.51 (0.38 to 0.63) ] .6489 Very Fair or Fair (n=79) 0.56 (0.45 to 0.67) Olive or Dark (n=21) 0.24 (0.08 to 0.47) ] .0094 Senior Total (n=100) 0.48 (0.38 to 0.58) Male (n=46) 0.43 (0.29 to 0.58) Female (n=54) 0.52 (0.39 to 0.65) ] .4035 Very Fair or Fair (n=83) 0.51 (0.40 to 0.61) Olive or Dark (n=17) 0.35 (0.14 to 0.62) ] .2497 All Respondents Total (N=400) 0.50 (0.45 to 0.55) Male (n=182) 0.43 (0.36 to 0.51) Female (n=218) 0.56 (0.49 to 0.63) ] .0124 Very Fair or Fair (n=322) 0.55 (0.50 to 0.61) Olive or Dark (n=17) 0.29 (0.19 to 0.40) ] .0000 Note. Sample proportions are given as the decimal followed by the 95% CI. Two-proportion Z-tests were used to determine significance. All P-values are two-sided. Artificial Tanning 16 Discussion This study quantified information about teenagers who tan indoors and sought a thorough investigation of their motivations for such behavior. Its findings show that a sizeable minority (24%) of students at a large suburban high school have patronized a tanning salon in the last year. As Table 3 illustrates, gender and age were determining factors in whether students tanned. As expected, significantly more girls tanned than boys, attributed to the increasing social pressure to appear tan and the heightened willingness of girls to invest in their appearances. While being considerable, the prevalence of indoor tanning observed is not extraordinary when compared to the pool of national surveys that have documented similar trends. A study conducted in 1999 by Geller et al. (2002) of 10,079 American adolescents age 12 to 18, showed that 10% of respondents patronized an indoor tanning salon in the previous year. Girls reported far greater tanning bed use (14%) than boys (2.4%), and tanning bed use increased from 7% among girls age 14, to 16% by age 15, and then doubled to 35% by age 17. Although the data collected show almost twice the prevalence of indoor tanning than demonstrated in this study, the overall trends in tanning salon use are similar. Similarly, a study of 6,903 non-Hispanic White adolescents in the United States found that 36.8% of females and 11.2% of males have been indoor tanning at least once, and 28.1% of females and 6.9% of males reported indoor tanning three or more times (Demko, Borawski, Debanne, Cooper, & Stange, 2003). In addition, the Demko et al. study showed that the percentage of female adolescents using artificial tanning 3 or more times increased with age: only 11.2% of the 13 to 14 year-olds reported tanning 3 Artificial Tanning 17 or more times, compared with 47.0% of the 18 to 19 year-olds. Furthermore, the study highlighted an interesting geographical explanation as to why many Midwestern teenagers tan indoors: “the risks of artificial tanning need increased emphasis among adolescents, especially in the Midwest and South where extremes in the availability of natural light appear to send intentional tanners indoors”(p. 854). This may explain why more teenagers in the Midwest, like those surveyed, tan indoors than the numbers that tan on a national level. Obviously, the popularity of indoor tanning is on the rise, and it is evident that those who tan indoors are beginning to do so at a younger age. On average, freshmen tanners began tanning at a significantly younger age than juniors or seniors, indicating that this trend will only continue to become more serious with time. It is important to note that local legislation in the area where this study was conducted currently bans teenagers less than 14 years of age from tanning and requires parental consent for 14 to 17 year-olds. However, there is evidence to suggest poor compliance with this law, as 18% (95% CI= 0.10 to 0.26) of tanners surveyed would have been unable to tan indoors at their first visit if this legislation had been enforced. Other studies have similarly documented poor compliance with state and federal regulations. One study of 50 tanning facilities in North Carolina found that 95% of patrons exceeded FDA recommended exposure limits (Hornung, Magee, Lee, Hansen, & Hsieh, 2003). Another study in San Diego found that 43% of tanning salons failed to comply with parental consent regulations (Culley, et al., 2001). As a whole, the tanning industry has effectively fought attempts by various organizations to bring national legislation Artificial Tanning 18 regulating indoor tanning, although it seems apparent that such legislation, if enforced, would help safeguard today’s youth from the harmful effects of UVR. Further analysis of the data collected for this study revealed that most tanners (57%) lacked a schedule for tanning and reported having only tanned between one to five times in the last year. Yet, 19% (95% CI= 0.11 to 0.29) of respondents who tanned specified that they did so more than 10 times in the last year. Sessions typically lasted 15 or 20 minutes, with no variation between the grade levels. The somewhat sporadic nature of tanning behavior may indicate that students tan indoors for specific events, rather than having an established regimen. An important goal of this research was to collect data on why students tanned indoors. As Table 4 demonstrates, the results of a multivariate analysis showed that the desire for a tanned appearance was the most prevalent incentive. Tanning for a school dance was also an important factor, giving credence to the idea that girls feel obligated to tan for social reasons. Unexpectedly, peer pressure did not play as large a role in a student’s decision to tan. This may be attributed to the individual nature of going to a tanning salon, along with the desire for teenagers to appear independent. Significant numbers of freshmen and juniors also went tanning prior to vacation, under the pretext of achieving a base layer. This concept is touted by the tanning industry, as evident in literature produced by the International Smart Tan Network (2002): “Every year, millions of indoor tanners successfully develop "base tans" before embarking on sunny vacations - tans that, combined with the proper use of sunscreen outdoors, help them prevent sunburn.” Although this statement may not be false, Artificial Tanning 19 achieving a “base tan” results in more UVR exposure than a person would ordinarily receive, possibly increasing the likelihood of developing skin cancers. The link between increased UVR exposure and skin cancer has been the subject of recent studies. Veierød, et al (2003) concluded that the use of an indoor tanning salon at any age increased the risk of developing melanoma by 55%. Furthermore, they noted that “adolescence and early adulthood appear to be among the most sensitive age periods for the effects of sunburn and solarium use on melanoma risk” (p.1530). Similarly, increased UVR exposure has been associated with increased risks for BCC and SCC, as found by Karagas et al. in 2002. These studies, while implicating UVR in the development of skin cancers, relied on older subjects (ages 25–74 in Karagas et al; and ages 30-50 years in Veierød, et al) to remember details about their past tanning salon practices. Although any survey is limited by the honesty of respondents and their ability to recall specifics from years ago, a strength of this study is the age group that was surveyed. Young respondents could provide reliable information about their recent tanning history. By documenting the extent to which teenagers use indoor tanning salons, rates of skin cancer can be tracked in the future to examine if the incidence of skin cancer can be attributed to increased UVR exposure by artificial tanning. A follow-up study of this nature would be of great value in providing evidence for this potential association. When analyzing how much UVR exposure a teenager receives, regular use of sunscreen is an important indicator. Half of all surveyed students indicated that they regularly used sunscreen, with freshmen having the highest proportion (64%) and sophomores having the lowest (40%). As Table 7 demonstrates, significantly more Artificial Tanning 20 females reported regular sunscreen use than males, supporting previous studies that have shown similar findings (Geller et al., 2002). It was expected that skin color would affect sunscreen use, and it was observed that those with very fair or average skin used sunscreen regularly more so than those with olive or dark skin. The most surprising finding here is that more students do not use sunscreen on a regular basis, even after extensive efforts to educate students about its importance. A similar discrepancy occurs with regard to education about artificial tanning. Table 6 details the exposure surveyed students had to various advertising, as well as their beliefs regarding the dangers of tanning. Although the vast majority of students (92%) thought artificial tanning was unhealthy, having seen educational material made no difference in their beliefs. However, tanners were more likely to have seen educational material than non-tanners. Interestingly, whether or not a respondent had gone tanning did not affect whether they had seen advertisements for tanning salons. This suggests that the tanning industry has effectively marketed their services to teenagers and that teenagers are learning about the dangers of tanning more from tanning salons then from any other source. This poses a significant problem that signals the limited nature of national campaigns to educate the public about the dangers of tanning. Currently, The Centers for Disease Control and Prevention (CDC) hosts the “National Melanoma/Skin Cancer Detection and Prevention Month” each May and publishes “Guidelines for School Programs to Prevent Skin Cancer.” Other organizations, such as the American Cancer Society and the American Academy of Dermatology have accessible web pages and produce pamphlets. Yet each of these organizations, while attempting outreach, would Artificial Tanning 21 benefit from improvement with their efforts. In the communities where this survey was conducted, no educational material about skin cancer or artificial tanning could be found in any schools. There is evidently a lack of educational resources committed to this problem. With national attention focused on epidemics such as AIDS and SARS and issues such as teen pregnancies and drug abuse, one must question why the trend in artificial tanning has been so overlooked. The most likely explanation is the concept of immediacy. AIDS, SARS, teen pregnancies and drug abuse all have swift consequences that activists can focus on, whereas indoor tanning provides immediate fulfillment but has delayed ramifications. Although there is a fear that today’s teenagers will be tomorrow’s cancer patients, the tanning industry continues to grow with little legislative restraint, threatening to engage more teenagers in the dangerous behavior of indoor tanning. Although 73% (95% CI=0.68 to 0.78) of respondents who didn’t tan indicated they refrained from tanning because they knew it was dangerous, the link between education and action is lacking. A recent survey of Midwestern teens indicated that most knew that excessive sun exposure was unhealthy, but that didn’t stop them from burning (Robinson, Rademaker, Sylvester, Cook, 1997). This is the essential problem faced by those who seek to curb this trend. It is necessary therefore to develop an educational campaign that is more than just pamphlets and advertisements. School systems, where students are potentially educable and the infrastructure exists to implement a well-designed campaign, must take action. The school where this study was conducted holds different “Awareness Weeks” on a frequent basis, each one educating students about a different subject. It is Artificial Tanning 22 surprising that there has never been a week highlighting the dangers of tanning, nor even interest in such a campaign. In addition, each sophomore is required to take a health class, but a unit about the dangers of artificial tanning is not in the curriculum. Clearly, this school does not stand alone; there are similar institutions across the nation that would benefit from such programs. Finally, it is the responsibility of parents and doctors to get involved as well. An adult educational campaign might prove as useful as one directed at students, considering that 11% (95% CI= 0.08 to 0.14) of respondents indicated that a parent in the household went tanning. If parental consent is required until the age of 18, educated parents could curtail their own use of tanning salons and stop their children from tanning at a young age. Ultimately, the prevalence of tanning indoors may be the product of a society focused on aesthetic appearances and one which is willing to overlook long-term ramifications. With the knowledge of why students tan indoors, more effective educational campaigns can be created to stem this trend. One of the strengths of this study was the pointed questions it asked of both tanners and non-tanners alike. Questions were designed to gather as much useful information as possible without asking students to recall facts they probably could not, such as the exact number of tanning salon visits in the last year, the type of UVR exposure they had, and the extent to which they were naturally exposed the UVR. Furthermore, to my knowledge, this study is the first which analyzes the motivations of students at a single high school, providing data on class-specific factors that shed light on how tanning behaviors mirror the school environment. Students surveyed are receiving one of the best educations in Artificial Tanning 23 the United States, yet this is not apparent in the widespread use of tanning salons. Finally, by comparing this study to others performed in different geographic regions, the extent to which location is a factor in tanning behavior can be determined. A limitation of this study was the homogeneity of the population surveyed. In addition, some variables were deemed unusable due to the nature of responses. It is likely that in a series of questions that were not highly invasive, students were surprised to be asked whether or not they smoked. Anecdotal evidence would suggest that many respondents hesitated to answer this question and then proceeded to answer “no.” The variable was examined because previous research had linked artificial tanning to other risky behaviors such as smoking (Welchsler, Rigotti, Gledhill-Hoyt, & Lee, 1998). Finally, while non-response bias was not exceptionally high, little attempt was made to analyze those who refused the survey. In the near future, a continuation of this study would begin by analyzing the effects of more pervasive educational intervention. Respondents of this survey would be contacted so that any change in their behavior or attitudes toward indoor tanning could be measured. This research would provide feedback to the creators of the educational campaign, allowing them to determine the most effective measures before attempting to introduce the program at another school. In an effort to sway public opinion, a nationwide, school-based initiative would likely be the most effective means of helping students realize the dangers they expose themselves to by patronizing indoor tanning facilities. Artificial Tanning 24 References American Academy of Dermatology. (1996). The darker side of tanning. Retrieved December 30, 2003, from http://www.aad.org/pamphlets/ darker.html Cokkinides, V. E., Weinstock, M. A., O'Connell, M. C., & Thun, M. J. (2002). Use of indoor tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: prevalence and correlates [electronic version]. Pediatrics. Retrieved on January 15, 2004, from http://www.findarticles.com/cf_dls/ m0950/6_109/87564111/print.jhtml Culley, C. A., Mayer, J. A., Eckhardt, L., Busic, A. J., Eichenfield, L. F., Sallis, J. F., Quintana, P. J. E., & Woodruff, S. I. (2001). Compliance with federal and state legislation by indoor tanning facilities in San Diego [Abstract]. Journal of American Academy of Dermatology, 44, 53-60. Demko, C. A., Borawski, B. A., Debanne, S. M., Cooper, K. D., & Stange, K. C. (2003). Use of indoor tanning facilities by white adolescents in the United States. Archives of Pediatric Adolescent Medicine, 157, 854-860. Geller A. C., Colditz G., Oliveria S., Emmons K., Jorgensen C., Aweh, G. N., & Frazier A. L. (2002). Use of sunscreen, sunburning rates, and tanning bed use among more than 10 000 US children and adolescents. Pediatrics, 109, 1009- 1014. Gutfeld, G., & Sangiorgio, M. (1993, May). Fake and bake. Prevention, 45(5), 6. Retrieved December 29, 2003, from MAS Ultra - School Edition database. Artificial Tanning 25 Hornung, R. L., Magee, K. H., Lee, W. J., Hansen, L. A., & Hsieh, Y. (2003). Tanning facility use: Are we exceeding Food and Drug Administration limits? [Abstract]. Journal of American Academy of Dermatology, 49, 655-61. The International Smart Tan Network. (2002). The fundamental truth about tanning. Retrieved December 29, 2003, from http://www.tanningtruth.com/ page.php Karagas, M. R., Stannard, V. A., Mott, L. A., Slattery, M. J., Spencer, S. K., & Weinstock, M. A. (2002). Use of tanning devices and risk of basal cell and squamous cell skin cancers [Electronic version]. Journal of the National Cancer Institute, 94, 224-226. Knight, J. M., Kirincich, A. N., Farmer, E. R., & Hood, A. F. (2002). Awareness of the risks of tanning lamps does not influence behavior among college students. Archives of Dermatology, 138, 1311-1315. Mathews, Jay. (2003). The most challenging American high schools. The Washington Post Company. Retrieved on January 1, 2004, from http://www.washingtonpost.com/wpsrv/education/shoulders/challenge/2003nation alindex.htm Robinson, J. K., Rademaker, A. W., Sylvester, J. A., & Cook, B. (1997). Summer sun exposure: Knowledge, attitudes, and behaviors of Midwest adolescents. Preventive Medicine, 26(3), 364-372. The Skin Cancer Foundation. (2003). Actinic keratosis: What you should know about this common precancer. Retrieved January 24, 2004, from http://www.skincancer.org/ak/index.php Artificial Tanning 26 The Skin Cancer Foundation. (2003). The case against indoor tanning. Retrieved December 29, 2003, from http://www.skincancer.org/ artificial/index.php The Skin Cancer Foundation. (2003). Skin cancer facts. Retrieved January 24, 2004, from http://www.cancer.org/docroot/PED/content/ped_7_1_ What_You_Need_To_Know_About_Skin_Cancer.asp?sitearea=PED The Skin Cancer Foundation. (2003). Sunlight and ultraviolet exposure. Retrieved January 24, 2004, from http://www.cancer.org/docroot/PED/ content/ped_7_1_What_You_Should_Know_About_Ultraviolet_Exposure.asp?sit earea=PED 2002-2003 Profile of: XXXX High School. (2003). Retrieved January 1, 2004, from http://www8.district125.k12.il.us/docs/profiles/ profile0203.html Veierød, M. B., Weiderpass, E., Thörn, M., Hansson J., Lund, E., Armstrong, B., & Adami, A. (2003). A prospective study of pigmentation, sun exposure, and risk of cutaneous malignant melanoma in women. Journal of the National Cancer Institute, 95, 1530-1538. Welchsler, H., Rigotti, N. A., Gledhill-Hoyt, J., & Lee, H. (1998). Increased levels of cigarette use among college students: a cause for national concern. Journal of the American Medical Association, 280, 1673-1678. Artificial Tanning 27 Westerdahl J., Ingvar C., Masback A., Jonsson N., & Olsson H. (2000). Risk of cutaneous malignant melanoma in relation to use of sunbeds: further evidence for UV-A carcinogenecity [Electronic version]. British Journal of Cancer, 82, 1593-1599. XXXX High School. (2003). Illinois School Report Card. Artificial Tanning 28 Appendix A Respondent Survey 2004 Hello, my name is XXXX and I am a student at XXXXX High School. I am conducting a survey about the effects of artificial tanning. Please, do you have a minute to answer a few questions? Thank you. First, what is your gender? Male (1) Female (2) How old are you? 14 15 16 17 18 19 th th th th What grade are you in? 9 (1) 10 (2) 11 (3) 12 (4) What is the normal color of your skin when it is not tan on the following scale? very fair (1) fair or average (2) olive (3) dark (4) Do you regularly use sunscreen? Yes (1) No (2) Do you think artificial tanning is healthy? Yes (1) No (2) Have you ever been to a tanning salon? Yes (1) No (2) (IF NO, SKIP THIS NEXT LINE OF QUESTIONING) IF YES: At what age did you first visit a tanning salon? 10 11 12 13 14 15 16 17 18 19 How many times have you gone tanning in the last year on the following scale? 1-5 (1) 6-10 (2) greater than 10 (3) Have you ever gone tanning for a school dance, like homecoming, turnabout or prom? Yes (1) No (2) On average, how often do you visit the tanning salon on the following scale? Once a week (1) Twice a week (2) Three times a week (3) Once a month (4) Twice a month (5) Three times a month (6) Different Schedule (7) No schedule (8) How long do you tan at each session on the following scale? 5 min 10 min 15 min 20 min 25 min 30 min Please respond with “true or false” to each of the following descriptions: a) I went tanning because I like how it makes me look. T (1) F (2) b) I went tanning because I got coupons or it was inexpensive. T (1) F (2) c) I went tanning because many of my friends do it. T (1) F (2) d) I went tanning to get a base layer before going on vacation. T (1) F (2) (IF YES, SKIP THIS NEXT LINE OF QUESTIONING) IF NO: Please respond with “true or false” to each of the following descriptions: a) I have no desire to go artificial tanning. T (1) F (2) b) I don’t go tanning because I know it is dangerous. T (1) F (2) c) I don’t go tanning because I don’t have enough time. T (1) F (2) d) I don’t go tanning because I don’t have the money. T (1) F (2) Artificial Tanning 29 FOR ALL: Does anyone in your family go tanning, if so, who? Mom (1) Dad (2) Brother (3) Sister (4) No one (5) Other (6) Do you think artificial tanning is safe? Yes (1) No (2) Have you ever seen advertisements for tanning salons? Yes (1) No (2) Have you ever seen an educational sign, pamphlet, or advertisement expressing the dangers of tanning? Yes (1) No (2) Do you smoke cigarettes? Yes (1) No (2) Do you have a license and access to a car? Yes (1) No (2) Okay, that’s it. Thank you very much for your time and have a great day. Bye!
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